Glenn Krauss’ Post

Over 100 hospitals, health systems, and providers have jointly advocated for enhanced Centers for Medicare & Medicaid Services oversight regarding Medicare Advantage (MA) denials. Premier Inc., a leading healthcare services company, spearheaded the initiative, urging CMS Administrator Chiquita Brooks-LaSure to mandate thorough data collection on MA claim denials and enforce compliance with Medicare coverage guidelines.   Premier's survey findings underscored the severity of the issue, revealing that while 15% of claims to private payers are denied, Medicare Advantage claims face a slightly higher denial rate of 15.7%. Moreover, hospitals incur an average administrative cost of $47.77 per appeal for denied Medicare Advantage claims.   In their letter to CMS, the healthcare entities emphasized the importance of monitoring MA plans' expenditure on direct patient care to ensure alignment with beneficiaries' entitlements. Notable healthcare providers, including CommonSpirit Health, Ascension, and AdventHealth, joined the call for CMS action.   Our RCM team plays a vital role in supporting hospitals by analyzing denial patterns, identifying underlying causes, and implementing effective strategies to minimize denials. Leveraging our expertise in Medicare Advantage regulations, we facilitate efficient appeals processes and advocate for fair reimbursement, ultimately striving to alleviate financial burdens on hospitals and uphold patient care standards.   We are the One!   #revenuecycle #revenuecyclemanagement #priorauthorization #medicalbilling #medicalcoding #healthcare #healthcaretechnology #accountsreceivables #denialmanagement #consulting #management #implementationpartner Becker's Healthcare

Major shifts in Medicare Advantage are taking place, including a crucial component of a new regulation—the extension of the two-midnight benchmark rule to MA plans. Our latest blog, “New Medicare Advantage Rule: Implications for Healthcare Providers and Patients,” unpacks the game-changing rule from the Centers for Medicare & Medicaid Services (CMS). Learn what it means to health systems and hospitals moving forward here: https://hubs.li/Q02Rzdxp0 #RCMblog #revenuecyclemanagement #rcm #HealthcareFinance #MedicareAdvantage #HealthcarePolicy #CMS #CMSUpdates #HealthcareInnovation #revenuecyclemanagementsupport #healthcare #healthcarercm #healthcarelegislation

The American Medical Group Association (AMGA) has urged congressional leaders to prioritize provider stability by incentivizing value-based care, preventing further Medicare payment cuts, and safeguarding the Medicare Advantage program. Despite recent legislative efforts to improve Medicare Part B reimbursement and extend value-based program incentives, AMGA stresses the need for additional policy actions to support multispecialty medical groups in maintaining quality care delivery. Providers have faced significant Medicare Part B reimbursement reductions over the past four years, risking furloughs, service reductions, and delayed investments in social determinants of health. AMGA highlights the urgency to address impending Medicare program cuts triggered by the Pay-As-You-Go rules. The Value in Health Care Act aims to extend incentive payments for Advanced Alternative Payment Models and reform policies in the Medicare Shared Savings Program, recommendations supported by AMGA. Additionally, AMGA opposes changes in Medicare Advantage policies that could compromise care access and financial stability for providers. They advocate for reforms like the Pharmacy Benefit Manager Reform Act to enhance data exchange and waivers for chronic care management code coinsurance requirements for Medicare beneficiaries. Our Revenue Cycle Management (RCM) consultants assist healthcare entities by optimizing billing processes, minimizing denials, maximizing reimbursement, and ensuring compliance with evolving regulations. We provide tailored strategies to address challenges, enhance financial performance, and support sustainable healthcare delivery. We are the One! #revenuecycle #revenuecyclemanagement #priorauthorization #medicalbilling #medicalcoding #healthcare #healthcaretechnology #accountsreceivables #denialmanagement #consulting #management #implementationpartner Xtelligent Healthcare

The Centers for Medicare & Medicaid Services (CMS) has finalized its Calendar Year (CY) 2025 Medicare Physician Fee Schedule (PFS) rule, which includes a 2.83% reduction in the payment conversion factor, lowering it to $32.35 from $33.29 in 2024. The rule also strengthens primary care, supports preventive services, and continues telehealth waivers, but it raises significant concerns for healthcare providers. Many doctors face increasing difficulty in navigating the complexities of Medicare reimbursements, with declining payment rates and rising administrative burdens. The National Association of ACOs and the American Academy of Family Physicians have voiced concerns about reduced financial targets, which are putting physician practices at risk and hindering access to care. New quality reporting requirements also necessitate costly investments in technology, but without providing actionable data, making it harder for practices to stay afloat. In this challenging landscape, Monarch MPS can help by streamlining the reimbursement process, ensuring that physicians get the reimbursements they deserve while reducing the administrative burden. Monarch MPS offers services designed to simplify billing, optimize payment collections, and help practices navigate the complexities of Medicare to improve cash flow and patient care. As CMS continues its push for an equitable healthcare system, healthcare providers need efficient solutions to thrive in a changing environment. Monarch MPS is here to help practices adapt and succeed. #Medicare #HealthcareReimbursement #PrimaryCare #Telehealth #HealthEquity #PhysicianFeeSchedule #ACO #MonarchMPS #PhysicianSupport #HealthcareSolutions

Many studies have shown that appropriate use of primary care services improves health outcomes and reduces healthcare costs. Yet despite its proven value, the United States devotes a much smaller share of each healthcare dollar to primary care than most developed countries do. Our healthcare system’s neglect of primary care is a particular problem in Medicare, whose fee schedule under-reimburses or entirely fails to reimburse many routine primary care services, including crucially important care coordination. New bipartisan legislation, known as the Pay PCPs Act of 2024, seeks to remedy this by encouraging CMS to adopt “hybrid payments” for primary care providers that would combine capitated and value-based payments for under-reimbursed services with fee-for-service payments for other services. According to the bill’s sponsors, Senators Sheldon Whitehouse (D-RI) and Bill Cassidy (R-LA), the payment model would ensure primary care providers a more predictable revenue stream, facilitating better integrated care that will improve quality while reducing costs.

Value-based care and delivery system transformation progress continues as the Medicare Shared Savings Program (MSSP) achieves its largest net savings to date, $2.1 billion in 2023 and improved scores in quality measures (be them as they may) according to results released earlier this week. ▪MSSP accountable care organizations (ACOs) earned $3.1 billion in shared savings payments and scored better on quality measures than other non-MSSP physicians. ▪MSSP ACOs led by primary care providers realized significantly higher net per capita savings. ▪As of Jan. 2024, there were 480 MSSP ACOs in which more than 680,000 clinicians participating covering close to 11 million Medicare beneficiaries. Kind of blows the mind having watched and commented on the program since inception. #MSSP #Valuebasedcare

🌟 Exciting News in Medicare Policy! 🌟 The Centers for Medicare & Medicaid Services (CMS) has announced significant updates in the Contract Year 2025 Medicare Advantage and Part D Final Rule. These changes focus on enhancing access, promoting competition, and ensuring that Medicare Advantage and Part D plans best serve enrollees' needs. At Abel Personnel, we understand the importance of having the right team in place to navigate complex healthcare regulations. Our expertise in staffing solutions ensures that healthcare organizations can meet these new requirements seamlessly. Looking for enrollment staffing solutions? Reach out to Abel Personnel at 717-561-2222 or visit www.abelpersonnel.com to discover how we can support your needs. Read more about the Contract Year 2025 Medicare Advantage and Part D Final Rule here: https://lnkd.in/e--b3t47 #MedicarePolicy #EnrollmentSolutions #HealthcareStaffing

During a Senate Budget Committee hearing, witnesses and lawmakers criticized Medicare for contributing to America's flawed healthcare payment system. They highlighted Medicare's fee schedule as a major factor, blaming it for creating imbalances in healthcare delivery and exacerbating the primary care crisis. The Relative Value Scale Update Committee (RUC), responsible for recommending reimbursement rates to Medicare, was singled out for undervaluing primary care services.   This devaluation, coupled with the fee-for-service payment system, leads to underinvestment in primary care and encourages costly procedures over diagnostic services.   Proposed solutions include adopting hybrid payment models and ensuring primary care spending in alternative payment arrangements. Concerns were raised about the lack of support for diverse and rural providers, with calls for equity-focused models and increased technical assistance.   The committee chairman expressed optimism about reforming the payment system to promote innovation and improve patient care, emphasizing the need for bipartisan legislation.     Devalued primary care and fee-for-service model disproportionately impact underserved communities, exacerbating healthcare disparities and hindering access to quality care.   To address the issue, implementing hybrid payment models, increasing support for primary care, and prioritizing equity-focused approaches are essential steps toward healthcare system reform.   Our RCM team can assist in optimizing revenue cycles, streamlining billing processes, negotiating with payers, and providing financial analysis to help healthcare providers maximize revenue and improve overall financial performance.   We are the One!   #revenuecycle #revenuecyclemanagement #priorauthorization #medicalbilling #medicalcoding #healthcare #healthcaretechnology #accountsreceivables #denialmanagement #consulting #management #implementationpartner MedPage Today

Over 100 hospitals and healthcare systems are pressuring the Centers for Medicare & Medicaid Services (CMS) to address rising Medicare Advantage claim denials. A letter signed by healthcare giant Premier on behalf of its members urges CMS to: - Collect more data on denials by Medicare Advantage plans. - Take action against plans that violate coverage rules. - Increase oversight of how much plans spend on direct patient care. - Prohibit delays or denials of claims approved through electronic prior authorization. - Give greater weight to patient experience in plan ratings. A Premier survey found a slightly higher denial rate for Medicare Advantage claims (15.7%) compared to claims submitted to private insurers (15%). Hospitals spend an average of $47.77 to appeal a single denied Medicare Advantage claim. Hospitals warn that excessive denials and bureaucratic hurdles create a financial burden and potentially compromise patient care. The letter highlights the importance of ensuring Medicare Advantage plans meet "medical loss ratio" (MLR) requirements, which dictate how much revenue must be spent on patient care. A growing number of healthcare systems are criticizing Medicare Advantage practices, with some even considering dropping the program entirely. Learn more: https://hubs.ly/Q02qQnNv0

As noted in the Becker's article at the link, S&P Global predicts that hospitals can expect more reimbursement challenges in the coming year, driven by demographic shifts and an increase in Medicare beneficiaries. Factors such as a growing Medicare patient mix, steady increase of denials, Medicare Advantage administrative challenges, federal emphasis on Medicare Advantage, and regulatory and legislative programs to control federal payer costs will put pressure on providers. The report also highlights the trend of health systems terminating Medicare Advantage contracts and the potential for changes to Medicare and Medicaid programs that could impact provider revenues.